Prior to 2000, Unum’s Group Plans and policies were issued from a category referred to as “XL” or “XLL”. These Plans lacked clarity and resulted in Unum’s infamous “blue memos” directing claims handlers to deny claims outside the Plan or contract.The XL series of Group Plans had more loopholes than Swiss cheese, and caused Unum to incur considerable losses.
As a result, a new series of Plan contracts emerged, closing the loopholes, and adding provisions Unum could easily pull out of its scalp belt, anytime, and for any claim. The new ERISA series called “CXC” Plans included provisions and Glossary definitions that Unum could easily defend in court.
One of these “specialized” provisions is called “Regular and Appropriate Care.”Regular Care” refers to reasonable frequency of consultation and treatment, and “Appropriate Care” requires treatment by a physician qualified to treat a claimed disability.
Most Unum Plans include the following provision:
REGULAR CARE means:
– you personally visit a physician as frequently as is medically required, according to generally accepted medical standards, to effectively manage and treat your disabling condition(s); and
– you are receiving the most appropriate treatment and care which conforms with generally accepted medical standards, for your disabling condition(s) by a physician whose specialty or experience is the most appropriate for your disabling condition(s), according to generally accepted medical standards.
Depending on the skill of the Unum manager/claims handler, this provision can be used to attempt to coerce or force claimants to receive certain types of treatment under threat of claim denial.
To begin, claimants cannot be forced to engage in any type of treatment by an insurance company. In my view claimants could actually be killed from ill advice given by an untrained medical RN or handler not having access to claimant medical history and personal examination results. Only treating physicians can determine regular and appropriate care.Unum is not in a position to force treatment not recommended by health providers as part of a treatment plan or goals objectives.
Unum is more successful denying claims under the “Regular and Appropriate Care” provisions than one might think largely because physicians fail to document what they DO consider “regular and appropriate care” for their patients. However, letters from Unum are worded to suggest that if you do not prove you are in appropriate care, claims will be denied.
Claimants should NEVER allow Unum, or any other insurer, dictate what regular and appropriate care is. For example, if Unum insists you have carpal tunnel surgery, you should respond, “I am currently seeking additional physical evaluation to determine if CTS surgery is of benefit and a viable treatment option at this time.” It is never a good idea to become so scared that you immediately jump into surgery when it is not indicated at the time, or shown to be of any future value to you.
Remember, that “Regular and Appropriate Care” provisions were added to the CXC series Plans to close loopholes and attempt to give Unum more control over what care is received. I wouldn’t want any insurance company making decisions about my health care, and you shouldn’t either. This provision is used by very cleaver claims handlers who can’t find ways to deny claims in other ways.
